Echocardiography –

Systolic Function &

Diastolic Dysfunction
Dr Kong Poi Keong
Hospital Pulau Pinang
Tues 10 Oct 2017
 Contents
1. Differentiate systolic from diastolic dysfn
2. Relate LV sys & dias dysfn to pt Mx
3. Classify sys & dias dysfn
4. LVSysD– 2-D (Bi-plane Simpson’s)
– 2-D (Wall Motion Score Index)
– M-mode of MV annulus (MAPSE)
– TDI of MV annulus (S’ or MASV)
5. LVDiasD – PW of MV Inflow (E:A) & PW of
Pulmonary Vein (S:D)
– TDI of MV annulus (e’)
 1. Comparison
between systolic &
diastolic dysfunction
 Sys dysfn vs diast dysfn
1. Sys dysfn = impaired ventricular contraction
(weak ventricle) = impaired ejection
2. Dias dysfn = impaired ventricular relaxation
(stiff ventricle) = impaired filling
3. Need normal LV dias fn to vacuum blood
from lungs & normal LV sys fn to pump into
aorta
 2. Relationship of
systolic & diastolic
dysfunction to patient’s
management
 Relationship of LVSysD to pt Mx
1. If LVSysD, blood not pumped into aorta will
stay in the lungs (pulm oedema). Pt becomes
breathless, congested & fatigued (triad of HF)
& has increased mortality
2. In acute LVSysD, needs diuretic (eg
furosemide) to clear APO +/- needs inotrope
to increase cardiac output/BP
3. In chronic LVSysD, needs ACEI (to reduce
salt & water retention), beta blocker (to
prevent overworking the heart) +/- diuretic
 Relationship of LVDiasD to pt Mx
1. If LVDiasD, blood not injected into LV will
stay in the lungs (pulm oedema). Pt becomes
breathless, congested & fatigued (triad of HF)
& may have increased mortality
2. Usually asymptomatic if normal heart rate or
normal rhythm. If tachycardia, time for
completing LV relaxation is shortened &
above occurs. If AF, 20% contribution from
LA to LV is lost & above occurs
 Relationship of LVDiasD to pt Mx
3. In acute LVDiasD, needs needs diuretic (eg
furosemide) to clear APO +/- treatment for
tachycardia/AF & their aetiologies (eg ACS,
pneumonia, anaemia, thyrotocicosis)
4. In chronic LVDiasD, needs to reduce BP
(major cause of LVH leading to LVDiasD),
normalise HR & relax the LV (reduce its
contractility) +/- needs diuretic. Most anti-HT
do some or all eg ACEI, beta blockers,
calcium channel blockers or diuretic
3. Classification of
systolic & diastolic
dysfunction
 LVSysD classification

Ejection fraction (%)

Normal >55
Low normal 50-55
Mild 40-50
Moderate 30-40
Severe <30
 LVDiasD classification

Normal Normal
Grade 1 Impaired relaxation
Grade 2 Pseudo-normalisation (LAP ↑)
Grade 3 Restrictive (reversible) (LAP ↑↑)
4. LV Systolic
Dysfunction
 LVSysD – 2-D (Single-plane Simpson’s)

1. Severity of LVSysD is measured in EF

2. EF can be estimated from eye-balling, M-
mode (fractional shortening FS & Teichoz) or
Simpson’s
 LVSysD – 2-D (Single-plane Simpson’s)
3. In single-plane Simpson’s, LV in diastole (eg
A4Ch) is cut into n slices with each slice
thickness L/n. Assuming circular LV with
diameter D, then each disk volume is π
(D/2)2 ) L/n = ¼ π D2 L/n. LVEDV = sum of all
disk volumes
4. Repeat with LV in systole to get LVESV
5. Hence EF=(LVEDV – LVESV)/LVEDV x
100%
(note: LVEDV-LVESV = stroke volume)
LVSysD – 2-D (Single-plane Simpson’s)
LVSysD – 2-D (Modified Bi-plane Simpson’s)
1. Circle is not assumed & D is not assumed to
be same in all directions on each slice
2. In diastole, in each slice, D1 is taken in A4Ch
& D2 in A2Ch
3. Disk volume = π (D1 /2) (D2 /2) L/n
= ¼ π D1 D2 L/n
4. LVEDV = sum of all disk volumes
5. Repeat with LV in systole to get LVESV
LVSysD – 2-D (Modified Bi-plane
Simpson’s)
 LVSysD – 2-D
(Wall Motion Score Index or WMSI)
LVSysD – 2-D (WMSI)
 LVSysD – 2-D (WMSI)

1. LV long-axis divided to basal, mid, apical &

apex
2. LV short-axis basal & mid are divided to ant,
ant septal, inf sept, inf, inf lat & ant lat
segments &
LV short-axis apical is divided to ant, septal,
lat & inf.
(apex has no further division)
Hence 17 segments
LVSysD – 2-D (WMSI)
 LVSysD – 2-D (WMSI)
1. PSAX – all 6 segments for basal & mid
levels, all 4 segments for apical level

2. PLAX (or ALAX) – ant sept vs inf lat

A4Ch – inf sept vs ant lat
A2Ch – ant vs inf
LVSysD – 2-D (WMSI)
 LVSysD – 2-D (WMSI)
1. Each segment is scored by its systolic
thickening & motion:
1 normo/hyperkinesia
2 hypokinesia
3 akinesia
4 dyskinesia (paradoxical sys motion)
5 aneurysm (dias deformation) (outpouching)

2. WMSI = sum of all scores

number of segments visualised
ie high WMSI = impaired LV systolic function
LVSysD – M-mode of MV annulus (MAPSE)
(Mitral Annular Plane Systolic Excursion)

M-mode in A4Ch at
lateral MV annulus

Caliper from ED to
ES (Normal > 1cm)
LVSysD – TDI of MV annulus (S’ or MASV)
(Mitral Annular Systolic Velocity)

SV of TDI in A4Ch at
lateral MV annulus

Normal S’ > 10cm/s

5. LV Diastolic
Dysfunction
 LVDiasD – PW of MV Inflow (E:A)

SV of PW at tip of MV in A4Ch

E/A > 1 E/A < 1 E/A > 1 E/A >>1

LVDiasD – PW of Pulmonary Vein (S:D)

SV of PW at PV

S ≥ D = good LV diastolic
function

S < D (systolic blunting) +/-

deeper A reversal = impaired
LV diastolic function
DiasD – TDI of MV annulus (e’)
SV of TDI at medial
MV annulus (lower
but more stable e’
than lateral)
e’ deep = good LV diastolic
function

e’ shallow = impaired LV diastolic

function
LVDiasD – combining PW & TDI (E/e’)